J.

 Swimming  Research,  Vol.  23  (2015)  

 
 
Development  and  Validation  of  a  Swimmer's  Functional  Pain  
Scale  
 
Coaching  Application  
 
Shawn  M.  Drake1,  Brian  Krabak2,  George  T.  Edelman3,  Erin  Pounders1,  Sharmon  
Robinson1,  Brittany  Wixson1  
 
1Arkansas  State  University  

PO  Box  910    
Jonesboro  (State  University),  Arkansas,  USA  
 
2Rehabilitation,  Orthopedics  and  Sports  Medicine  

University  of  Washington  and  Seattle  Children’s  Sports  Medicine  

1959  N.E.  Pacific  Street  
Seattle,  Washington,  USA  
 
399  Wolf  Creek  Blvd.,  Suite  2  

Dover,  Delaware,  USA  

 
Abstract  
Swimmers  frequently  complain  of  shoulder  pain  sometime  during  their  careers.    The  
purpose  of  this  study  was  to  develop  and  validate  a  self-­‐administered  questionnaire  that  
measures  pain  and  functional  status  of  the  shoulder  in  swimmers  that  may  alert  a  coach  
or  swimmer  to  seek  follow  up  with  a  healthcare  provider.    Participants  completed  the  
developed  Swimmer’s  Functional  Pain  Scale  (SFPS)  and  compared  it  to  another  
questionnaire  designed  for  other  sports.    Fifty-­‐eight  USA  Swimming  age  group  and  
collegiate  swimmers  completed  the  SFPS.    Results  of  this  study  indicated  that  the  SFPS  is  a  
valid  and  reliable  tool  for  swimmers  to  determine  when  a  referral  to  a  healthcare  
provider  is  appropriate.  
 
Introduction  
 

Competitive  swimmers  place  high  demands  on  their  shoulders  by  excessive  shoulder  
revolutions  and  power  strokes.      Shoulder  pain  is  common  at  all  levels  of  the  sport.    
From  the  local  recreational  club  programs  that  may  have  a  part-­‐time  coach  with  
limited  resources,  to  the  center  of  excellence  programs  with  full-­‐time  coaches  that  are  
training  elite  level  and  professional  athletes.      Swimmers  may  train  as  many  as  6-­‐8  
workouts  each  week  for  50  weeks  each  year.    The  high  training  volume  results  in  few  
opportunities  for  a  swimmer  to  take  a  break  from  the  sport  to  allow  the  shoulders  to  
recover  from  the  high  demands.      
 

  1  
 J.  Swimming  Research,  Vol.  23  (2015)  
 
 
Coaches  deal  with  shoulder  pain  in  their  swimmers  on  a  daily  basis.    Often,  the  coach  
must  determine  the  extent  of  the  problem  and  make  decisions  on  whether  to  allow  a  
swimmer  to  continue  or  discontinue  swimming  and  seek  a  health  care  provider.    The  
cause  of  the  pain  can  be  many  and  based  on  the  background  of  the  coach,  it  can  be  
challenging  for  them  to  determine  the  extent  of  the  pain/injury.  
 
The  perception  of  pain  and  the  relative  nature  of  pain  can  be  interpreted  differently  
from  one  culture  to  another  and  one  athlete  to  another.    It  is  natural  for  an  intense  
swimming  workout  or  consecutive  intense  workouts  to  contribute  to  shoulder  
soreness.      Muscle  soreness  is  expected  in  the  competitive  athlete;  however,  pain  may  
be  a  sign  of  potential  anatomical  damage.    Differentiating  pain  from  soreness  and/or  
interpreting  the  athlete’s  perception  of  pain  can  be  challenging  for  the  athlete  and  
coach.  
 
Pain  scales  are  common  in  medicine  and  sports  activities.    There  are  a  number  of  
functional  measurement  tools  for  the  upper  extremity.  However,  these  tools  are  not  
specific  to  swimming.    Pink  et  al.  (2010),  first  proposed  a  measurement  tool  for  
swimming  to  help  categorize  pain  and  provide  strategies  for  management  of  shoulder  
pain.    The  pain  scale  mimics  the  typical  visual  analog  pain  scale,  which  uses  a  10  cm  
horizontal  line  to  mark  and  measure  the  pain.    The  pain  scale  designed  by  Pink  et  al.  
(2010)  provided  guidelines  for  management  strategies  related  to  shoulder  pain,  
including  the  need  for  a  referral  to  a  health  care  professional.    The  tool  categorizes  pain  
into  four  zones  that  correspond  to  increasing  levels  of  pain.    The  four  zones  include  a  
white,  yellow,  orange  and  red  zone.    Each  zone  has  descriptions  that  are  intended  to  
help  the  coach  and  athlete  label  the  discomfort.    For  example,  "shampoo  arm  
syndrome"  (i.e.  the  athlete  has  difficulty  shampooing  his/her  hair  after  workout)  
corresponded  to  a  pain  level  of  3  (Figure  1).    The  treatment  for  a  swimmer's  reported  
pain  level  of  3  included  ice,  but  the  athlete  could  still  complete  a  full  workout  even  
though  the  athlete  minimized  certain  strokes  to  avoid  pain.  
 

  2  
 J.  Swimming  Research,  Vol.  23  (2015)  
 
 
Figure  1.    Shampoo  arm  syndrome  is  characterized  by  shoulder  pain  while  the  swimmer  washes  
his  or  her  hair.  
The  purpose  of  this  study  was  to  develop  and  validate  a  self-­‐administered  
questionnaire  that  measures  pain  and  functional  status  of  the  shoulder  in  swimmers  
that  may  alert  a  coach  or  swimmer  to  seek  follow  up  with  a  healthcare  provider.    The  
Swimmer’s  Functional  Pain  Scale  (SFPS)  focuses  on  pain  during  the  swimmer’s  
functional  activities  (see  figure  2)  both  in  the  water  and  out  of  the  water  with  activities  
of  daily  living.    The  investigators  adapted  the  initial  measurement  tool  from  Pink  et  al.  
(2010)  and  added  functional  components  to  help  arrive  at  the  pain  zones.    The  SFPS  
uses  guiding  questions  about  functional  activity  to  determine  the  score  instead  of  using  
the  10  cm  visual  analog  scale  (VAS).  
 

 
Figure  2.    Swimmer  Functional  Pain  Scale  focuses  on  pain  and  functional  status  of  the  shoulder  in  
swimmers.  
 
An  expert  panel  of  swim  coaches,  physical  therapists  and  sports  medicine  physicians  
reviewed  the  SFPS  and  provided  feedback  prior  to  field-­‐testing.    The  SFPS  requires  the  
competitive  swimmer  to  answer  a  series  of  yes/no  questions  (flow  chart)  regarding  
his/her  level  of  pain  and  soreness.    The  final  score  of  the  SFPS  represents  a  score  from  
0-­‐10,  which  in  turn,  falls  into  one  of  the  four  zones:  white,  yellow,  orange  or  red.    Each  
zone  represents  increasing  pain  levels  similar  to  a  visual  analog  scale  and  also  provides  
specific  treatment  protocols  as  proposed  by  Pink  et  al.  (2010).  
 
Discussion  
 

  3  
 J.  Swimming  Research,  Vol.  23  (2015)  
 
 
Managing  athletic  injuries  is  an  important  component  of  coaching.    Having  a  self-­‐
reported  functional  outcome  measure  is  important  for  evaluating  functional  limitations  
and  treatment  effectiveness.  Currently,  there  are  few  tools  for  swim  coaches  to  use  on  
deck  to  help  decipher  a  swimmer’s  complaints.    Identifying  a  potential  injury  and  
taking  corrective  measurements  is  vital  to  the  overall  success  of  the  athlete  and  the  
performance  of  the  team/program.        
 
The  incidence  of  shoulder  problems  in  swimmers  can  range  from  41%  to  as  high  as  
91%  depending  on  the  competition  level.    The  majority  of  swim  coaches  have  limited  
knowledge  regarding  evaluation  and  treatment  of  injuries.    Recognizing  when  a  
swimmer  needs  to  seek  the  advice  of  a  healthcare  provider  is  helpful.    The  SFPS  
questionnaire  provides  a  self-­‐reported  measurement  tool  for  swimmers  and  coaches  to  
guide  their  decisions  on  who  may  need  a  modification  to  their  training  and  who  may  
need  to  seek  further  formal  evaluation  of  his  or  her  shoulder  pain.  
 
The  aim  of  this  study  was  to  determine  the  reliability  and  concurrent  validity  for  the  
SFPS.    The  SFPS  is  a  self-­‐reported  pain  scale  that  is  reliable  in  the  tested  population  of  
swimmers  and  is  found  to  have  good  validity.    The  simplicity  of  the  SFPS  could  be  
beneficial  by  providing  clinically  relevant  information  to  the  swim  coach  for  deciding  
whether  a  swimmer  should  continue  swimming  or  seek  the  evaluation  of  a  health  care  
provider.  
 
Application  
 

While  testing  the  SFPS  questionnaire,  two  swimmers  were  subsequently  referred  to  a  
healthcare  provider.    The  following  two  cases  include  one  collegiate  swimmer  and  one  
age  group  swimmer.  
 
Case  1.    A  collegiate  swimmer  reported  “swimming  with  pain”  and  scored  a  9  (red  
zone)  on  SFPS  and  a  29.2  on  the  KJOC.    At  this  point,  the  coach  would  refer  the  
swimmer  to  a  health  care  provider.    For  this  swimmer,  a  physical  therapist  further  
evaluated  the  swimmer  to  determine  if  a  referral  would  be  appropriate.    Shoulder  pain  
occurred  with:  1)  shoulder  flexion  and  adduction,  2)  shoulder  abduction  and  external  
rotation,  and  3)  shoulder  extension  and  internal  rotation.    Additionally,  the  swimmer  
was  unable  to  perform  the  functional  push-­‐up  test  due  to  shoulder  pain  (Figure  3).    The  
swimmer  was  referred  to  the  college’s  athletic  trainer  for  follow-­‐up  and  shoulder  
rehabilitation.    The  swimmer  returned  for  post-­‐testing  4-­‐weeks  later  and  reported  
“swimming  with  pain”  and  scored  a  7  (orange  zone)  on  the  SFPS  and  scored  a  39.2  on  
the  KJOC.  On  follow-­‐up,  she  reported  pain  with  1)  shoulder  flexion  and  adduction  and  
2)  shoulder  extension  and  internal  rotation.    She  did  not  report  pain  with  shoulder  
abduction  and  external  rotation.    The  swimmer  was  still  unable  to  perform  a  push-­‐up  
in  the  pain-­‐free  range.    This  swimmer  continued  to  swim  and  had  not  returned  to  pain-­‐
free  swimming  at  the  4-­‐week  post-­‐test.  
 
 

  4  
 J.  Swimming  Research,  Vol.  23  (2015)  
 
 

 
Figure  3.    Performing  a  functional  push-­‐up  test.      
 
Case  2.    One  Age  Group  swimmer  scored  a  9  on  the  SFPS  and  was  referred  to  a  health  
care  provider.    At  the  4-­‐week  retesting  phase,  the  coach  indicated  that  the  swimmer  
was  receiving  physical  therapy  for  biceps  tendonitis  and  was  not  available  for  follow-­‐
up  testing.    Two  months  later,  researchers  followed  up  with  this  swimmer,  and  the  
swimmer  had  returned  to  pain-­‐free  swimming.    (The  second  swimmer  was  not  
included  in  data  analysis  because  she  did  not  complete  post-­‐testing.)      
 
Summary  
Coaches  must  determine  the  appropriate  time  to  refer  a  swimmer  to  a  health  care  
provider  for  shoulder  related  pain.    Unfortunately,  differentiating  pain  related  to  
muscle  soreness  versus  pain  due  to  injury  is  difficult.    The  results  of  the  SFPS  indicate  
that  the  self-­‐reported  pain  scale  is  reliable  in  the  tested  population  of  swimmers.    The  
simplicity  of  the  SFPS  allows  coaches  at  all  levels  to  apply  the  questionnaire  on-­‐deck  
and  help  them  make  decisions  that  will  be  in  the  best  interest  of  the  athlete.  
 
 
 
 
   
 
   
 

  5  
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